[醫如往常] Senior Clerkship Day 91: Lab Medicine: Diagnostic Hepatology

Hepatology 陳醫師

data異常一定要去看病人

Hyperglycemia-> 可能是從D5W IV側抽血造成的

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AST

• 80% mitochondria
• Half-life 17 hrs
• Acute >10x

ALT

• Chronic
• Half-life 47 hrs
• Acute >10x
• Viral (>2000IU is very dangerous)
• Jaundice 70% HAV(good prognosis), 35%HBV, 25%HCV
• Mild fever通常是HAV，糞便要用lysol消毒，vaccination兩劑撐廿年，incubation 1mo，症狀出現之前糞便就有病毒
• HBV分八種genotype，華人常見BC, C outcome很差，不過genotype在biofunction沒有甚麼實際差異。疫苗要>10IU/ml才有保護力。Anti-Hbe spontaneous seroconversion 10-20% annually. Adult得的<5% 變carrier

	HBsAg	HBsAb	HBeAg	HBcAb	HBV DNA
Acute	+	-	+	IgM	+
Clerared infection	-	+	-	IgG	-
vaccinated	-	+	-	-	-
Inactivated carrier	+	-	-	IgG	<2000IU/ml
Chronic infection with active replication	+	-	+/-	IgG	>2000IU/ml

• HCV 80%會變成carrier, asymptomatic,
• HEV: High risk for pregnancy->fulminant hepatic failure. Window period 6-8 weeks.

• Ischemia
• Toxin/drug (3000IU是正常的，排除underlying就OK) Ex: statin (2.5% population)
• Autoimmune
• Type 1
• ANA (Cytoplasmic); anti nuclear antibody
• ASMA; anti smooth muscle antibody
• AAA; anti actin antibody
• Type 2
• ALKM1; anti liver kidney microsomal I antibody
• ALCM; anti liver cytosol 1 antibody

Ref.周貝倫 自體免疫性肝炎 - Taiwan Society of Internal Medicine http://www.tsim.org.tw/journal/jour20-3/03.PDF

• Early phase of obstruction (jaundice & pain)
• PBC; Primary Biliary Cirrhosis: AMA
• PSC; Primary Sclerosing Cholangitis
• Gallstones, CBD stones, pancreatic cancers

• AST/ALT 3-5X
• NASH; non-alcoholic steatohepatitis
• 不一定fat有關，可能跟biofilm有關
• 可能變成HCC
• Asymptomatic
• Gilbert syndrome
• 2-10% population
• Unconjugated bilirubin levels fluctuate
• No risk of kernicterus to the fetus (不用浪費錢驗bilirubin)
• R/o hemolysis
• Wilson's disease
• Low Ceruloplasmin (homozygous 65-95%, heterozygous 20%)

Factors

• BMI
• Exercise: Independent AST↑
• Hemolysis: AST↑ ALT↑ Red urine, Occult blood, pale face, dizziness
• Rhabdomyolysis: AST↑ ALT↑ Red urine, Occult blood(-), pale face(-)

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Gamma GT

• Confirm ALP↑ due to hepatic source
• Alcohol
• Drugs: statin
• BMI
• steatohepatitis (一般視為正常人)

ALP

• Liver and bone
• BMI, pregnancy
• Marker of cholestasis
• Half-life 1 week
• 可以用ALP isoenzyme (很貴), 5-NT, gamma GT 驗證

Conjugation Bilirubin

• Exercise
• Hemolysis
• Hemolytic anemia

INR

Thrombocytopenia

• Liver fibrosis

Albumin

• Half-life 19-21 days
• Nephrotic syndrome
• Burns
• Enteropathy
• SIRS

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	ALP	AST	ALT	GGT	T-bil	TP	Albumin
Hepatocellular pattern	-	↑	↑	-
Cholestatic pattern	↑	-	-	↑
Mixed pattern	↑	↑	↑	↑

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對於無症狀的人，做預防醫學

抽Anti-Hbs IgG, anti-HCV, Anti-HAV IgG

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對於 RUQ pain, jaundice, fever, AST/ALT>1000 U/L
抽Anti-Hbc IgM, HbsAg, Anti-HAV IgM, anti-HCV (rare acute onset)